This form may take you 20 minutes to fill in.

Instructions

1. Please write clearly in BLOCK LETTERS. Complete all sections and indicate ‘NA’ for items not applicable.

2. Certified true copies of your birth and educational certificates, testimonials and other relevant documents must be produced when requested.

3. False particulars or intentional withholding of information will disqualify you, or if already awarded, terminate the scholarship.

4. SLAwill not enter into correspondence with regard to reasons for non-selection of applicant.

Proposed Programme & Institution

(Please indicate the university and the course of study you are currently pursuing)

Course of Study/ Institution______

Current Year of Study______

Personal Particulars

Full Name in BLOCK Letters ______

(underline surname, include aliases)

Name in Chinese Character ______

(if applicable)

Race ______Religion ______

Date of Birth ______Age ______Marital Status______Gender: *Male / Female

*NRIC (Pink) / NRIC (Blue)/ Passport No. ______Citizenship No. (if any) ______

Country of Birth: *Singapore / Malaysia / Others ______

Present Citizenship: ______Previous Citizenship (if any) ______

Address ______

Tel No. (H) ______Tel No. (O) ______Tel No. (HP/Pg) ______

E-mail Address ______

Educational Details

Academic Qualifications

School / Institution / From / To / Highest Standard Passed

* delete accordingly
Secondary School Academic Records

GCE ‘O’ Level or Equivalent / Name of Exam / GCE ‘A’ Level or Poly Final Year Result or Equivalent / Name of Exam
Year Taken / Year Taken
Subjects / Grade / Grade / Subjects / Grade / Grade
Year of Exam / Results
TOFEL
SAT I
No. of ‘O’ Level Passes / SAT II

Tertiary Academic Records

University Attended: / Country:
Course of Study: / Merit: Yes/No* / Class of Hons: Year:
Subject / Grade / Subject / Grade
GPA for latest/final year * results:

Core-Curricular Activities

Sports / Uniformed Groups/ Society & Club Activities / Describe Your Participation / Period (month & year)
From / To

Academic Scholarships & Awards

From (Year) / To (Year) / Name of Scholarship/ Award

Employment History

Position Held / Name of Employer / Duration / Basic Salary
(Last Drawn)
From / To

National Service Records

(If applicable, please submit a copy of your SAF Certificate of Service with your application)

Full-Time □Part-Time □Exempted □ ______

(if exempted, state reason)

Completed □Yet-to-Serve □Not Applicable □

Rank ______Vocation ______

Enlistment Date ______ORD ______

Name of Camp ______CampTelNo. ______

Family Details

(Please provide the following information of all immediate family members, i.e., parents and siblings. If you are married, please provide your spouse and children’s.)

Name ______Relationship ______Age ____ Citizenship ______

Marital Status ______Occupation ______Current Salary per Month ______

Name of Employer / School ______

Name ______Relationship ______Age ____ Citizenship ______

Marital Status ______Occupation ______Current Salary per Month ______

Name of Employer / School ______

Name ______Relationship ______Age ____ Citizenship ______

Marital Status ______Occupation ______Current Salary per Month ______

Name of Employer / School ______

Family Details

Name ______Relationship ______Age ____ Citizenship ______

Marital Status ______Occupation ______Current Salary per Month ______

Name of Employer / School ______

General

Language Proficiency:

Spoken ______

Written ______

Hobbies & Interests -- Level of Proficiency (if applicable, e.g., Piano Grade V)

1. ______

2. ______

Character Referees

Name ______Occupation ______

Name of Organisation ______Contact No.______

Period Known ______Address ______

Name ______Occupation ______

Name of Organisation ______Contact No.______

Period Known ______Address ______


General Information

1. Have you ever suffered or are you suffering from medical condition, illness, disease, mental illness or Yes / No*

physical impairment?

2. (a) Do you have a criminal record 1 in Singapore? Yes / No*

(b) Have you ever been convicted in a court of law in any country (excluding parking offences or criminal Yes / No*

records disclosed above)?

3. Have you been charged with any offence in a court of law in Singapore or in any country for which the Yes / No*

outcome is pending (excluding parking offences)?

4.Are you aware of being under any current police investigations in Singapore or in any other country Yes / No*

following allegations made against you?

5. Have you been or are you under any financial embarrassment, ie, (a) an undischarged bankrupt, Yes / No*

(b) a judgement debtor, (c) have unsecured debts and liabilities of more than 3 months of last drawn pay,

(d) have signed a promissory note or an acknowledgement of indebtedness?

6. If your answer to any of the above questions is “Yes”, please give details.

______

______

7. Have you applied or are applying for any other scholarship? If yes, please give details. Yes / No*

a) Name of Scholarship ______Course ______

Organisation ______Outcome of Application ______

b) Name of Scholarship ______Course ______

Organisation ______Outcome of Application ______

8. From which source did you first learn of our scholarship?

Scholar’s Choice □ Scholarship Guide□ SLA Website □ School□ Friends □ Others □ ______

(please specify)

Declaration

I declare that the information given in this application form and any sheets attached is correct and accurate and I have not wilfully suppressed any material facts. I understand that submission of false particulars or wilful suppression of material facts will disqualify me or terminate the scholarship if I am so offered.

Signature of Applicant ______Date ______

1 By this, we refer only to a criminal record of a conviction under the Registration of Criminals Act

SLA Scholarship 020506